Sexual and reproductive function in end-stage renal disease and effect of kidney transplantation

Current treatment options for erectile dysfunction in kidney transplant recipients

INTRODUCTION

Erectile dysfunction (ED) and kidney dysfunction share common risk factors linked to conditions involving endothelial impairment, such as coronary artery disease, dyslipidemia, diabetes mellitus, hypertension, smoking, and obesity. Men with chronic kidney disease experience a high incidence and prevalence of ED. While a functional renal graft can alleviate the issue for some patients, a significant portion of recipients still experience ED (20%-50%).

OBJECTIVES

This narrative review describes the variety of current treatments modalities on ED in kidney transplant recipients (KTRs) and their clinical outcomes.

METHODS

MEDLINE, Web of Science, PubMed, and Google Scholar were used to find eligible articles pertaining to the treatment options of ED in KTRs. A total of 64 articles were evaluated.

RESULTS

In KTRs, ED stems from a multifaceted etiology: anxiety, drug side effects, interference with penile vascularity, or the response of cavernosal muscle to neurotransmitters, along with changes in the endocrine milieu. A diverse range of treatments to restore erectile function has proven to be safe and effective for KTRs. Options include drug therapy, surgical interventions, intracavernosal injection therapies, vacuum erection devices, and extracorporeal shockwave therapy.

CONCLUSION

The initial treatment approach may involve the use of a phosphodiesterase type 5 inhibitors at a low dosage, especially if testosterone-circulating levels align with the diagnosis of hypogonadism. The consideration of a combination therapy involving testosterone and phosphodiesterase type 5 inhibitors should be contemplated due to the associated beneficial effects. Extracorporeal shockwave therapy has shown positive short-term clinical and physiological effects on erectile function in patients who did not respond to first-line treatments, resulting in spontaneous erections sufficient for sexual penetration in 50% of cases. Penile implants should be considered as third-line options based on specific patient needs and compliance with clinical conditions.

NGF, EPO, and IGF-1 in the Male Reproductive System

Several studies have demonstrated interesting results considering the implication of three growth factors (GFs), namely nerve growth factor (NGF), erythropoietin (EPO), and the insulin-like growth factor-I (IGF-1) in the physiology of male reproductive functions. This review provides insights into the effects of NGF, EPO, and IGF-1 on the male reproductive system, emphasizing mainly their effects on sperm motility and vitality. In the male reproductive system, the expression pattern of the NGF system varies according to the species and testicular development, playing a crucial role in morphogenesis and spermatogenesis. In humans, it seems that NGF positively affects sperm motility parameters and NGF supplementation in cryopreservation media improves post-thaw sperm motility. In animals, EPO is found in various male reproductive tissues, and in humans, the protein is present in seminal plasma and testicular germ cells. EPO receptors have been discovered in the plasma membrane of human spermatozoa, suggesting potential roles in sperm motility and vitality. In humans, IGF-1 is expressed mainly in Sertoli cells and is present in seminal plasma, contributing to cell development and the maturation of spermatozoa. IGF-1 seems to modulate sperm motility, and treatment with IGF-1 has a positive effect on sperm motility and vitality. Furthermore, lower levels of NGF or IGF-1 in seminal plasma are associated with infertility. Understanding the mechanisms of actions of these GFs in the male reproductive system may improve the outcome of sperm processing techniques.

Clinical Implications and Risk Factors for Erectile Dysfunction in Kidney Transplant: A Single-Center Assessment

BACKGROUND

Erectile dysfunction (ED) affects the great majority of people undergoing dialysis and also the majority of patients undergoing kidney transplantation. In this study, we investigated the degree of erectile dysfunction (ED), as well as its prevalence, contributory variables, and overall impact after renal transplant.

METHODS

Adult male kidney transplant patients were the subject of an observational, non-interventional study that was conducted at a single center. Age, time and type of dialysis before transplantation, comorbidities, factors associated with cardiovascular risk, data on sexual history, physical examination, and laboratory results were among the clinical data we examined. In addition to gathering clinical and demographic characteristics, the International Index of Erectile Function (IIEF) questionnaire was used to evaluate sexual function.

RESULTS

A total of 170 renal transplanted patients between 20 and 70 years old (mean age: 45.40±11.5) were included in this study. All of the patients had immunosuppressive treatment with a calcineurin inhibitor (cyclosporine or tacrolimus) and had a normal glomerular filtration rate (GFR). The prevalence of sexual dysfunction increased with age (42.6% of patients under 40, 47.4% of patients in the 40-60 age group, and 78.9% of patients over 60). Mild, moderate, and severe ED was noted in 33.5%, 20.6%, and 10.6% of cases, respectively, and 51 (30%) patients reported having a normal sexual function. While calcium channel blockers (122 cases) were the most commonly used antihypertensive medication and chronic glomerulosclerosis (55.3%) was the most common cause of chronic kidney disease (CKD) before transplantation, none of these variables appear to have affected the severity of erectile dysfunction. The only medications associated with sexual dysfunction were alpha-blockers and aspirin (75 mg) (p=0.026 and p=0.013, respectively).

CONCLUSIONS

Although kidney transplantation has positive impacts on the quality of life, erectile dysfunction is a frequent condition among patients with renal transplants, and it has an increased frequency with age. In our study, it has been observed that only a small percentage of the research group had a normal sexual function, although most of the patients were young, and that alpha-blockers and aspirin (75 mg) are associated with erectile dysfunction.

Testosterone Deficiency as One of the Major Endocrine Disorders in Chronic Kidney Disease

Reduced testosterone concentration is nowadays thought to be one of the main endocrine disorders in chronic kidney disease (CKD). It is caused by the dysfunction of the hypothalamic-pituitary-gonadal axis. The role of testosterone is multifactorial. Testosterone is responsible not only for reproductive processes, but it is a hormone which increases bone and muscle mass, improves lipid profile, insulin sensitivity, erythropoiesis, reduces blood pressure, and ameliorates mood and perception. The implications of hypogonadism in CKD are infertility and loss of libido, reduction of muscle mass and strength, disorders in bone mineralization, the development of sarcopenia and protein energy wasting (PEW), progression of atherosclerosis, increased visceral adiposity, insulin resistance, and anaemia. Reduced testosterone serum concentrations in CKD are associated with increased mortality rate. Testosterone supplementation improves sexual functions, reduces the level of inflammatory markers and blood pressure, stimulates muscle protein synthesis, improves insulin sensitivity and lipid profile, and increases muscle mass, bone mineral density, and haemoglobin concentration. It positively affects mood and well-being. The modes of testosterone supplementation are intramuscular injections, subcutaneous pellets, and percutaneous methods—patches and gels. Successful kidney transplantation may improve gonadal function and testosterone production, however, half of men with low testosterone concentrations before kidney transplantation do not restore hormonal function.

Fertility and Pregnancy in End Stage Kidney Failure Patients and after Renal Transplantation: An Update

Sexual life and fertility are compromised in end stage kidney disease both in men and in women. Successful renal transplantation may rapidly recover fertility in the vast majority of patients. Pregnancy modifies anatomical and functional aspects in the kidney and represents a risk of sensitization that may cause acute rejection. Independently from the risks for the graft, pregnancy in kidney transplant may cause preeclampsia, gestational diabetes, preterm delivery, and low birth weight. The nephrologist has a fundamental role in correct counseling, in a correct evaluation of the mother conditions, and in establishing a correct time lapse between transplantation and conception. Additionally, careful attention must be given to the antirejection therapy, avoiding drugs that could be dangerous to the newborn. Due to the possibility of medical complications during pregnancy, a correct follow-up should be exerted. Even if pregnancy in transplant is considered a high risk one, several data and studies document that in the majority of patients, the long-term follow-up and outcomes for the graft may be similar to that of non-pregnant women.

Impact of Kidney Transplantation on Male Sexual Function: Results from a Ten-Year Retrospective Study

BACKGROUND

The effects of kidney transplantation on male sexual function are controversial.

AIM

To evaluate the impact of kidney transplantation on erectile and ejaculatory function and to assess a possible correlation between some selected characteristics of patients and their erectile and ejaculatory function after renal transplantation.

METHODS

An observational retrospective analysis was conducted on male patients who had undergone kidney transplantation from January 2009 to April 2019. A prospectively maintained database was used to collect all data. Patients were evaluated before kidney transplant and 6 and 12 months after kidney transplant. Male patients undergoing renal transplantation for any cause who were sexually active with a stable partner were included in the study.

OUTCOMES

The main outcome measures included the International Index of Erectile Function (IIEF-15) and the 4-item version of Male Sexual Health Quality-Ejaculation Disorders (MSHQ-EjD Short Form) questionnaires. The first 3 questions of the MSHQ-EjD Short Form were used to assess the ejaculatory function, whereas the fourth question was used to evaluate the ejaculation bother.

RESULTS

A total of 95 patients were eligible in the study. The evaluation of sexual function was available in 56 patients (58.9%). Mean IIEF-15 significantly decreased at 6 months (P < .001) remaining unchanged at 12 months (P = .228). Mean MSHQ-EjD Short Form (1-3) significantly decreased at 6-month follow-up (P < .001) and at 12-month follow-up (P = .024). Mean MSHQ-EjD Short Form (4) was significantly increased compared with the baseline at both 6 and 12 months (P < .05). IIEF-15 was significantly related to the MSHQ-EjD Short Form at 6-month and 12-month follow-up (P < .001). Age, diabetes, hypertension, smoking, pretransplantation testosterone, time for transplantation, baseline IIEF-15, and baseline MSHQ-EjD Short Form (1-3) were significantly associated (P < .05) with both IIEF-15 and the MSHQ-EjD Short Form (1-3) at 6-month and 12-month follow-up after kidney transplantation.

CLINICAL IMPLICATIONS

Improvement of knowledge regarding the effects of kidney transplantation on sexual function and about the patient characteristics related to sexual health after transplantation.

STRENGTH & LIMITATIONS

This is the first article that analyzes in depth the ejaculatory function in patients who had undergone kidney transplantation assessing ejaculation with a validated questionnaire. The main limitation is the retrospective design of the study.

CONCLUSION

Kidney transplantation appears to have a negative impact on sexual health, significantly worsening both erectile and ejaculatory functions. Age, diabetes, hypertension, smoking, pretransplantation testosterone levels, time for transplantation, as well as erectile and ejaculatory function before transplant were significantly related to erectile and ejaculatory functions after renal transplantation. Spirito L, Manfredi C, Carrano R, et al. Impact of Kidney Transplantation on Male Sexual Function: Results from a Ten-Year Retrospective Study. J Sex Med 2020;17:2191-2197.

Prevalence of erectile dysfunction in patients with chronic kidney disease: a systematic review and meta-analysis

Growing evidence reports that chronic kidney diseases (CKD) might play a role in erectile dysfunction (ED), but limited knowledge is available. Therefore, we performed a systematic review up to 21/08/2019 to investigate the associations between CKD and ED. The main analysis reported the prevalence of ED as absolute estimates (in %) with their 95% confidence intervals (CIs) and across CKD stages (when specified), hemodialysis and transplant, calculating the p for interaction across strata. Among 291 studies, we included 34 articles with 5986 men. We found an overall prevalence of 76% (95%CI: 72-79) with a high degree of heterogeneity (I² = 84.2%; p < 0.0001). Analyzing the data by CKD stage, we found a significant higher prevalence of ED in CKD (78%; 95%CI: 75-81%; I² = not possible) compared with hemodialysis stage (prevalence = 77%; 95%CI: 73-80%; I² = 84.5) or to patients undergoing transplant (prevalence = 64%; 95%CI: 54-74%; I² = 54%) (p across strata = 0.036). Considering the high prevalence of ED in men with CKD, health care practitioners should focus on issues of sexual health in men with CKD. Given the advancements in dialysis and therapy and the associated advancements in survival and life expectancy, maintaining the patients' sexual function is important for their well-being and quality of life.

Male infertility in renal failure and transplantation

The global disease burden of end stage renal disease (ESRD) is growing rapidly, and organ transplantation remains the gold standard for improving both the quality and quantity of life particularly in young adults. It is therefore critical to understand the effect of ESRD and renal transplantation on male fertility. Many men in renal failure exhibit subfertility or infertility due to several factors including hypogonadism, erectile dysfunction (ED), and direct impairment of spermatogenesis with spermatotoxicity and late stage maturational arrest causing oligospermia or azoospermia. Kidney transplantation has been shown to rescue some-but not all-of these defects, with normalization of reproductive hormonal parameters, improvement in semen parameters (sperm count, motility, morphology), and partial restoration of erectile function. This improvement in fertility is sufficient for a subset to father children either naturally or with assisted reproduction. In this review, we summarize the literature regarding fertility in men with chronic kidney disease (CKD) and on dialysis, and we describe the changes associated with renal transplantation.

Sexual dysfunction and male infertility

Infertility affects up to 12% of all men, and sexual dysfunction occurs frequently in men of reproductive age, causing infertility in some instances. In infertile men, hypoactive sexual desire and lack of sexual satisfaction are the most prevalent types of sexual dysfunction, ranging from 8.9% to 68.7%. Erectile dysfunction and/or premature ejaculation, evaluated with validated tools, have a prevalence of one in six infertile men, and orgasmic dysfunction has a prevalence of one in ten infertile men. In addition, infertile men can experience a heavy psychological burden. Infertility and its associated psychological concerns can underlie sexual dysfunction. Furthermore, general health perturbations can lead to male infertility and/or sexual dysfunction. Erectile dysfunction and male infertility are considered proxies for general health, the former underlying cardiovascular disorders and the latter cancerous and noncancerous conditions. The concept that erectile dysfunction in infertile men might be an early marker of poor general health is emerging. Finally, medications used for general health problems can cause sperm abnormalities and sexual dysfunction. The treatment of some causes of male infertility might improve semen quality and reverse infertility-related sexual dysfunction. In infertile men, an investigation of sexual, general, and psychological health status is advisable to improve reproductive problems and general health.

Successful pregnancy in a recipient of an ABO-incompatible renal allograft

Kidney transplantation restores fertility in patients with end-stage renal disease, with many successful pregnancies after kidney transplantation being reported. However, there are little data regarding pregnancy in women transplanted under modern-era desensitisation protocols that utilise rituximab, plasma exchange and intravenous immunoglobulin, including ABO-incompatible transplants. Pregnancies in ABO-incompatible recipients can pose new challenges from an immunological perspective. Here, we report a case of successful pregnancy using in vitro fertilisation, in a renal transplant recipient who underwent desensitisation two years prior, that included use of rituximab and plasma exchange to receive an ABO-incompatible transplant from her husband and subsequent father of the baby. We believe this was the first case of successful pregnancy after ABO-incompatible kidney transplantation in Australia and New Zealand. This case also highlights the difficulties faced in conception following transplantation and demonstrates that in vitro fertilisation utilising ovulation induction can be successfully utilised for conception in this cohort. This recipient also had gestational diabetes, worsening renal function and preterm delivery which are important complications often seen in pregnancies of solid organ transplant recipients.

What is the role of nephrologists and nurses of the dialysis department in providing fertility care to CKD patients? A questionnaire study among care providers

Purpose

This study evaluated current fertility care for CKD patients by assessing the perspectives of nephrologists and nurses in the dialysis department.

Methods

Two different surveys were distributed for this cross-sectional study among Dutch nephrologists (N = 312) and dialysis nurses (N = 1211).

Results

Response rates were 50.9% (nephrologists) and 45.4% (nurses). Guidelines on fertility care were present in the departments of 9.0% of the nephrologists and 15.6% of the nurses. 61.7% of the nephrologists and 23.6% of the nurses informed ≥50% of their patients on potential changes in fertility due to a decline in renal function. Fertility subjects discussed by nephrologists included “wish to have children” (91.2%), “risk of pregnancy for patients’ health” (85.8%), and “inheritance of the disease” (81.4%). Barriers withholding nurses from discussing FD were based on “the age of the patient” (62.6%), “insufficient training” (55.2%), and “language and ethnicity” (51.6%). 29.2% of the nurses felt competent in discussing fertility, 8.3% had sufficient knowledge about fertility, and 75.7% needed to expand their knowledge. More knowledge and competence were associated with providing fertility health care (p < 0.01).

Conclusions

In most nephrology departments, the guidelines to appoint which care provider should provide fertility care to CKD patients are absent. Fertility counseling is routinely provided by most nephrologists, nurses often skip this part of care mainly due to insufficiencies in self-imposed competence and knowledge and barriers based on cultural diversity. The outcomes identified a need for fertility guidelines in the nephrology department and training and education for nurses on providing fertility care.

Restoration of immune and renal function in aged females by re-establishment of active ovarian function

Proper immune functioning is necessary to maximize reproductive success. In addition, age-associated uremia in women is often associated with hypothalamic­–pituitary–gonadal dysfunction. In the present experiments, we tested immune and renal function to determine if exposure of postreproductive mice to young, reproductively cycling ovaries would influence non-reproductive physiological functions. Control female CBA/J mice were evaluated at 6, 13 and 16 months of age. Additional mice received new (60-day-old) ovaries at 12 months of age and were evaluated at 16 months of age. Consequently, 6-month-old control mice and 16-month-old recipient mice both possessed 6-month-old ovaries and were reproductively cycling. A significant age-related decline in immune function (T-cell subset analysis) was found in 16-month-old mice, but was improved 64% by ovarian transplantation. Renal function (blood urea nitrogen : creatinine ratio) was also decreased with aging, but ovarian transplantation restored function to levels found in 6-month-old mice. In summary, we have shown that immune and renal function, which are negatively influenced by aging, can be positively influenced or restored by re-establishment of active ovarian function in aged female mice. These findings provide a strong incentive for further investigation of the positive influence of young ovaries on restoration of health in postreproductive females.

Male patients with terminal renal failure exhibit low serum levels of antimüllerian hormone

Male reproductive function is impaired during end-stage renal disease (ESRD). Disturbance of the hypothalamic-pituitary-gonadal axis, and therefore the regulation of sex hormones, is one of the major causes. Our focus was to include antimüllerian hormone (AMH) and inhibin B concentrations. Twenty male patients on hemodialysis, median age 40 (26–48) years, were analyzed for follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, sex hormone-binding globulin (SHBG), testosterone, estradiol, AMH and inhibin B levels. We used 144 proven fertile men, median age 32 (19–44) years as a control group and analyzed differences using multiple linear regression. Males with ESRD demonstrated higher mean values for prolactin, 742 versus normal 210 mIE l⁻¹ (95% confidence interval (CI): 60.3, 729), LH, 8.87 versus normal 4.5 IE l⁻¹ (95% CI: 2.75, 6.14), and estradiol 89.7 versus normal 79.0 pmol l⁻¹ (95% CI: −1.31, −0.15). Mean value for AMH was lower, 19.5 versus normal 47.3 pmol l⁻¹ (95% CI: −37.6, −11.6). There were no differences found for FSH, SHBG, inhibin B and testosterone. The most important difference was found for AMH, a marker of Sertoli cell function in the testes, which decreased by close to 60% when compared with controls. Combined with an increase in LH, these findings may indicate a dysfunction of Sertoli cells and an effect on Leydig cells contributing to a potential mechanism of reproductive dysfunction in men with ESRD.

Female sexual function and depression after kidney transplantation: comparison between deceased- and living-donor recipients

Disturbances in sexual function and depression are a common feature in women with chronic renal failure. Living-donor kidney transplantation seems to warrant better results than its cadaveric counterpart in many aspects but its impact on post-transplantation sexual function remains unknown. This study aimed to compare post-transplantation sexual function and depression in women receiving kidney grafts from living and deceased donors. From a single-center prospective database of 2016 renal transplantations between June 2011 and June 2013, we enrolled 50 sexually active women after kidney transplantation. Female sexual function was evaluated with the Female Sexual Function Index Questionnaire (FSFI) and depression was assessed using the Beck Depression Inventory-II (BDI-II) scale. Thirty-four patients referred the questionnaires. The sexual domains of satisfaction and desire were significantly better in living-donor receptors; in all other domains evaluated by FSFI no statistically significant difference was encountered between groups, although living-donor receptors tended to report better function. Total BDI-II was well correlated with total FSFI score in our study cohort (Spearman's rho = -0.80, P < .001). Only 34.6% of women referred to have discussed sexual issues with their physicians before transplantation, whereas 73.1% stated it would have been important. In conclusion, living-donor transplantation exerted a positive effect on women's sexual function.

Urological Consequences following Renal Transplantation: A Review of the Literature

Renal transplant (RT) represents the treatment of choice for end-stage renal disease (ESRD) but harbours a wide range of possible complications and therapeutic challenges of urological competence. Dialysis years and clinical medical background of these patients are risk factors for sexual dysfunction and lower urinary tract symptoms (LUTS). On the contrary, RT itself may have a number of possible surgical complications such as ureteral stenosis and urinary leakage, while immunosuppressive treatment is a known risk factor for de-novo malignancies.

The present review describes the main urologic problems of RT patients and their up-to-date treatment options according to the most recently available literature evidences.

[Impact of end-stage renal disease and kidney transplantation on the reproductive system]

Chronic renal failure leads to many metabolic disorders affecting reproductive function. For men, hypergonadotropic hypogonadism, hyperprolactinemia, spermatic alterations, decreased libido and erectile dysfunction are described. Kidney transplantation improves sperm parameters and hormonal function within 2 years. But sperm alterations may persist with the use of immunosuppressive drugs. In women, hypothalamic-pituitary-ovarian axis dysfunction due to chronic renal failure results in menstrual irregularities, anovulation and infertility. After kidney transplantation, regular menstruations usually start 1 to 12 months after transplantation. Fertility can be restored but luteal insufficiency can persist. Moreover, 4 to 20% of women with renal transplantation suffer from premature ovarian failure syndrome. In some cases, assisted reproductive technologies can be required and imply risks of ovarian hyperstimulation syndrome and must be performed with caution. Pregnancy risks for mother, fetus and transplant are added to assisted reproductive technologies ones. Only 7 authors have described assisted reproductive technologies for patients with kidney transplantation. No cases of haemodialysis patients have been described yet. So, assisted reproductive technologies management requires a multidisciplinary approach with obstetrics, nephrology and reproductive medicine teams' agreement.

Semen quality in men with chronic kidney disease and its correlation with chronic kidney disease stages

The aim of this study was to assess whether chronic kidney disease (CKD) has any impact on semen quality parameters in men with CKD stage 1-5. Results were collected from 66 men with different CKD stages (age 18-50 years). Age and BMI (body mass index) were recorded for each male. Higher CKD stage had a significant negative linear trend on semen volume (P < 0.05), progressive motility (P < 0.01), nonprogressive motility (P < 0.001), sperm concentration (P < 0.01), total sperm number (P < 0.01), cytoplasmic droplets (P < 0.01), teratozoospermia index (P < 0.05) and accessory gland markers, α-glucosidase activity (P < 0.05), zinc (P < 0.01) and fructose (P < 0.01). BMI per se had no significant effect on semen volume, sperm number, sperm concentration, morphology, α-glucosidase activity, fructose concentration or zinc level. A significant negative correlation between BMI and sexual-hormone-binding globulin (SHBG) (P < 0.01) was observed but not with other sex hormones. Age per se was related to a significant decrease of sperm concentration (P < 0.05), normal forms (P < 0.01) and testosterone level (P < 0.05). Our results indicate that CKD stage per se is a factor determining the number of spermatozoa available in the epididymis for ejaculation, in part independent of age-related decrease of testosterone level and BMI.

Living versus cadaveric-donor renal transplant recipients: a comparison on sexual function

Erectile dysfunction is experienced by 50% of men with end-stage renal disease (ESRD) and uremia. The origin of this dysfunction is multifactorial. The aim of this study was to compare living donor versus cadaveric donor transplant recipients regarding male sexual function. Seventy-seven sexually active male kidney transplant recipients (44 from living donors; 33 from cadaveric donors) were randomly selected from our single-center prospective database of 2016 renal transplants. Epidemiological and clinical data were collected between June 2010 and June 2011. Male sexual function was evaluated with the International Index of Erectile Function questionnaire (IIEF-15). We assessed the prevalence of male sexual dysfunction according to established cutoff points for each of the IIEF-15 domains. Mann-Whitney and Pearson's chi- square statistical tests were used to compare continuous and categorical variables, respectively. The median age at the time of completion of the questionnaires was 43 and 51 years (P = .003) with median times from transplantation was of 36 and 42 months for living donor and cadaveric donor recipients, respectively (P = .31). Median durations of ESRD before surgery were 17.5 and 57 months for living donor and cadaveric donor recipients, respectively (P < .001). Living donor and cadaveric donor recipients had median creatinine clearance values of 55 and 57 mL/min, respectively (P = .44). Median time after renal transplantation for first sexual intercourse was 1 and 2 months for living donor and cadaveric donor recipients, respectively (P = .35). Median body mass indices for living donor and cadaveric donor recipients were 24.8 and 24, respectively (P = .31). Regarding sexual function domains, there were significant differences only for intercourse satisfaction. In our cohort, living donor recipients tended to be younger, have shorter time of ESRD, and less incidence of hypertension or diabetes mellitus but with greater tobacco use. In conclusion, living donor transplantation exerted a favorable impact on sexual function.

Sildenafil citrate can improve erectile dysfunction among chronic hemodialysis patients

Erectile dysfunction (ED) is common among patients with end-stage renal disease (ESRD), who undergo hemodialysis (HD). The aim of this study was to evaluate the safety and effectiveness of sildenafil in male HD patients with ED. Twenty-seven HD patients were recruited for this prospective, randomized, double-blind, placebo-controlled, clinical trial study of sildenafil during a period of 1 week. Efficacy was assessed by using the International Index of Erectile Function (IIEF) before and 1 week after treatment. Baseline demographic and clinical features were similar in both the groups. There was a weak correlation between ED and duration of undergoing dialysis (P = 0.073). There was significant relationship between sildenafil usage and improvement in erectile function (P < 0.0001). Placebo improved significantly the erectile function (P = 0.016), perhaps by psychological way. However, sildenafil had a more significant effect than placebo in increasing IIEF score among HD patients (P = 0.00 compared to 0.016). Sildenafil is effective and safe for treating ED among HD patients.

Measurements of serum pituitary-gonadal hormones and investigation of sexual and reproductive functions in kidney transplant recipients

Objective. To investigate changes in serum pituitary-gonadal hormones and restoration of sexual and reproductive functions after successful kidney transplantation. Patients and Methods. Serum pituitary-gonadal hormones before and after kidney transplantation were measured in 78 patients with end-stage renal disease (ESRD) and in 30 healthy adults. Pre- and postoperative semen specimens of 46 male recipients and 15 male controls were collected and compared. Additional 100 married kidney transplant recipients without children were followed up for 3 years to observe their sexual function and fertility. Results. Serum PRL, LH, and T or E₂ levels gradually restored to the normal ranges in all kidney transplant recipients, and sperm density, motility, viability, and morphology significantly improved in the male recipients 4 months after successful kidney transplantation (P < .05). Thirty-three male recipients (55.93%) reobtained normal erectile function, and 49 kidney transplant recipients (61.25%) had children within the 3-year follow-up period. Conclusion. Successful kidney transplantation could effectively improve pituitary-gonadal hormone disturbance and sexual and reproductive dysfunctions of ESRD patients.

Does erythropoietin affect motility of spermatozoa?

INTRODUCTION

Erythropoietin, which is a hematopoietic growth factor, has been found to play a role in various physiologic processes within the body including testicular steroidogenesis and spermatogenesis. However, it is not known whether erythropoietin is also essential for the normal physiology of mature sperm cells. In this study, the effects of recombinant human erythropoietin beta (rEPO) on sperm motility were investigated.

MATERIALS AND METHODS

Samples of 37 volunteers (with total motile sperm count>5x10(6)/ml and a total motility of >50% according to WHO criteria) were collected by masturbation following a 3-5 days period of abstinence. After morphometric analysis before and just after washing, samples were either used as control or treated with rEPO at concentrations of 0.1, 1, 10 or 100 mIU/ml, respectively. Control and treated tubes were incubated for 4 h at 37 degrees C.

RESULTS

Total motility, total progressive motility, slow forward and nonmotile sperm counts of 1, 10 and 100 mIU/ml rEPO groups were significantly improved. This effect was dose independent.

CONCLUSION

No significant effect was found at 0.1 mIU/ml concentration. These results suggest that supplementation of media used for sperm preparation techniques with erythropoietin might be beneficial. Further studies are needed to clarify the mechanism of action of erythropoietin on mature sperm cells.